ML20072R619
| ML20072R619 | |
| Person / Time | |
|---|---|
| Site: | Davis Besse  |
| Issue date: | 09/01/1994 |
| From: | Stetz J CENTERIOR ENERGY |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| 1-1050, NUDOCS 9409130262 | |
| Download: ML20072R619 (10) | |
Text
_.
l b.ENTEINOR C
ENERGY 300 Modson Avenue John P. Stetz Toledo, OH 43652-0001 Vice President - Nuclear 419 249-2300 Davis-Besse Docket Number 50-346 License Number NPF-3 Serial Number 1-1050 September 1, 1994 United States Nuclear Regulatory Commission Document Control Desk Vashington, D. C.
20555 Subj ec t : Response to Inspection Report 50-346/94006 (DRP)
Gentlemen:
Toledo Edison has received Inspection Report 94006 (Log Number 1-3063) and the enclosed Notice of Violation; the response to which is provided below. Toledo Edison recognizes the broader implications of the procedural adherence issues identified in this violation, particularly in light'of the increase in activities associated with the upcoming Ninth Refueling Outage.
Corrective actions taken in response to this violation vill focus on continuous improvement in this area at the Davis-Besse Nuclear Power Station.
Violation:
10 CFR Part 50, Appendix B, Criterion V, " Instructions, Procedures, and Drawings," states, in part, that
" Activities affecting quality shall be prescribed by documented instructions, procedures, or drawings... and-shall be accomplished in accordance with these instructions, procedures, or drawings."
Administrative procedure DB-MN-00005, Foreign Material a.
Exclusion (FME), defines an exclusion zone 3 as an area requiring access control over personnel and materials.
~ Controls to'do this include ropes / tape barriers, and signs around'the work area.
Material accountability (log), and personnel accountability (log) are required.
DB-MN-00005 specifies the spent fuel pool (SFP) as an exclusion zone 3 area.
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Cleveland Electnc lituminchng 9409130262 940901 l f.
PDR ADOCK 05000346 1
Docket Number 50-346 License Number NPF-3 Serial Number 1-1050 Page 2-Contrary to the above, from June 21 to June 30, 1994, FME was not adequate for the spent fuel pool area in that the FHE access barrier on the vest side of the pool had been removed.
In addition, the material accountability log was inaccurate, in that several items had not been logged in/out of the exclusion area (346/94006-01a(DRP)).
b.
Administrative procedure DB-MS-01637, Scaffolding Erection and Removal Guidelines, requires that scaffolding be constructed such that the gap between scaffold and equipment be at least 1 inch, and prohibits tying off the scaffolding to conduit or unistrut conduit supports.
(
Contrary to the above, on July 12, 1994, a scaffold in l
the #1 low voltage switchgear room was not erected in accordance with DB-HS-01637 in that a horizontal cross member aas in contact with a louvre of a safety l
related ventilation damper, and the scaffold was braced with wire to two 3-inch safety related conduits I
and a safety related unistrut conduit support (346/94006-01b(DRP)).
c.
Procedure DB-0P-00006, Night Order / Standing Order Log, I
note 6.1 states that " Night orders shall not provide instructions which conflict with or substitute for approved procedures."
Contrary to the above, the night order log sheet issued to the operating crews on January 13, 1994, contained instructions that conflicted with approved procedure DB-0P-06331, Freeze Protection and Electriccl Heat Trace, in that Section 3.2 of the procedure tequired work requests to be initiated for heat trace or freeze protection problems causing alarm conditions on the control room DORIC' recorder.
]
However, the rigit order stated that when a heat trace or freeze protec on problem was noted, the electrical
{
shop personnel v de to be notified.
If they were j
unable to review or solve the problem, submittal of the work request would then be allow d.
As a result e
of the conflicting guidance, work requests were not initiated for all heat trace and freeze protection
(
problems (346/94006-Olc(DRP)).
This is a Severity Level IV Violation (Supplement I).
Response
Accepta.Ne or Denial of the Alleged Violation Toledo Edison accepts the alleged violation.
Docket Number 50-346 License Number NPF-3 Serial Number 1-1050 Page 3 Reason for the Violation The three procedural adherence examples-identified in the victation indicate that management expectations regarding compliance with procedures are not being completely met.
In each case, a basic tenet of an administrative procedure was violated. While these violations were not blatant or malicious in nature, they are inconsistent with management procedural adherence expectation'.
Personnel are expected to exercise the discretion and discipline necessary to ensure that procedural requirements are met.
The number and comprehensive nature of Davis-Besse procedures demand a conscious, continuous, high level of attention to detail regarding procedural adherence by personnel at all levels of craft and management. The apparent cause of this violation is insufficient attention to detail on the part of the individuals performing the identified activities and insufficient reinforcement by management to ensure that procedural adherence expectations were met.
Corrective Actions Taken and Results Achieved Part as On June 30, 1994, Potential Condition Adverse to Quality Report (PCAQR) 94-0571 was initiated to document the procedure violation regarding inadequate foreign material exclusion in spent fuel pool area. The FHE access barrier was replaced and the FME material log was reconciled as part of PCAOR 94-0571 immediate actions.
Part b:
On July 12, 1994, PCA0R 94-0591 was initiated to document the procedure violation regarding a deficient scaffold installation in the #1 Lov Voltage Switchgear Room. The C[ cific deficiencies were immediately corrected.
All other scaffolding was subsequently inspected and no other db 'epancies were identified.
Part c:
On January 31, 1994, PCAOR 94-0114 was initiated to document the procedure violation regarding work requests not being initiated for heat trace and freeze protection problems.
Vork requests were initiated as required on February 1, 1994.
A memorandum was issued on February 15, 1994, by Electrical Maintenance which clarified the actions being taken to address heat trace and freeze protection problems and reinforced the expectation that work requests are required.
Required reading for Operations personnel was later initiated which reiterated the expectation that work requests are required for heat trace and freeze protection problems.
In addition, as'an enhancement, DB-OP-06331 is being revised to clarify expected actions to address this problem.
Docket Number 50-346
~
License Number NPF-3 Serial Number 1-1050 Page 4 Corrective Actions to Prevent Recurrence Toledo Edison recognizes the importance of procedural adherence to safe, reliable nuclear power plant operation.
It is Davis-Besse management's position that the procedural adherence issues identified by this violation, and their broader implications, are not the result of deficient employee training. Rather, these issues have developed over time due to a lack of sufficient reinforcement of management expectations and insufficient attention to detail on the part of plant staff.
A memorandum from the Vice President - Nuclear addressing procedural adherence issues will be distributed to all site personnel. This memorandum vill reinforce the management expectation that each employee is responsible for exercising the attention to detail, discretion, and discipline necessary to ensure that procedural requirements are met.
The memorandum vill be issued by September 2, 1994.
To further reinforce these expectations, employee meetings vill be conducted by Davis-Besse serior management to discuss procedural adherence issues. The meetings vill be conducted prior to the Ninth Refueling Outage which is scheduled to begin October 1, 1994.
Davis-Besse publishes a quarterly performance monitoring report using the " annunciator vindow" approach. The report monitors and trends a vide range of performance measures and provides Davis-Besse management with timely feedback on plant performance. The report consists of a visual display of colored vindows arranged in an annunciator panel format and is displayed on bulletin boards throughout the site.
Beginning in September 1994, and continuing initially for two full quarterly reporting periods, a focus vindov vill be developed and implenented to trend procedural adherence issues.
Following this initial period, the procedural adherence focus vindov vill be evaluated to assess the benefits of continually maintaining this vindow in the performance monitoring report.
Independent of this violation, potential programmatic compliance issues had already been identified through the trending of PCA0Rs. The Nuclear Assurance organization has initiated a Suspected Trend Investigation Report (STIR) which will, in part, address the procedural adherence issues identified by this violation and which may result in additional corrective actions.
J 1
Docket Number 50-346 License Number NPF-3 Serial Number 1-1050 4
Page 5 Date Vhen Full Compliance Vill Be Achieved Part as Full compliance was achieved on June 30, 1994, following the replacement of the FME access barrier and reconciliation of the FME material access log for the spent fuel pool area.
Part b:
Full compliance was achieved on July 13, 1994, following the inspection of plant scaffolding to ensure compliance with the requirements of DB-MS-01637.
Part c:
Full compliance was achieved on February 1, 1994, following_
the initiation of outstanding work requests for heat trace and freeze protection problems.
Should you have any questions or require additional information, please contact Mr. Villiam T. O'Connor, Manager - Regulatory Affairs, at (419) 249-2366.
Very truly yours, f{/
600 gdb VA/ eld cc:
L. L. Gundrum, NRC Project Manager J. B. Martin, Regional Administrator, NRC Region III S. Stasek, DB-1 NRC Senior Resident Inspector Utility Radiological Safety Board
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4 EffEHtCTY l
300 Madison Avenue John P. Stetz Toledo, OH 43652 0001 Vice President - Nuclear 419-249 2300 Davis-Besse Docket Number 50-346 License Number NPF-3 Serial Number 1-1050 September 1, 1994 United States Nuclear Regulatory Commission Document Control Desk Vashington, D. C.
20555 Subj ect :
Response to Inspection Report 50-346/94006 (DRP)
Gentlemen Toledo Edison has received Inspection Report 94006 (Log Number 1-3063) and the enclosed Notice of Violation; the response to which is provided below. Toledo Edison recognizes the broader implications of the procedural adherence issues identified in this violation, particularly in light of the increase in activities associated with the upcoming Ninth Refueling Outage.
Corrective actions taken in response to this violation vill focus on continuous improvement in this area at the Davis-Besse Nuclear Power Station.
e Violation:
10 CFR Part 50, Appendix B, Criterion V, " Instructions, Procedures, and Drawings," states, in part, that
" Activities affecting quality shall be prescribed by documented instructions, procedures, or drawings... and shall be accomplished in accordance with these instructions, procedures, or drawings."
Administrative procedure DB-MN-00005, Foreign Material a.
Exclusion (FME), defines an exclusion zone 3 as an area requiring access control over personnel and materials.
Controls to do this include ropes / tape barriers, and signs around the work area.
Material accountability (log), and personnel accountability (log) are required.
DB-MN-00005 specifies the spent fu11 pool (SFP) as an exclusion zone 3 ar?a.
Operating Companies-Cleveland Electnc illuminating Toledo Edson
Docket Number 50-346 License Number NPF-3 Serial Numbar 1-1050 Page 2 Contrary to the above, from June 21 to June 30, 1994, FME vas not adequate for the spent fuel pool area in that the FME access barrier on the vest side of the pool had been removed.
In addition, the material accountability log was inaccurate, in that several items had not eeen logged in/out of the exclusion area (346/94006-01a(DRP)).
b.
Administrative procedure DB-MS-01637, Scaffolding Erection and Removal Guidelines, requires that scaffolding be constructed such that the gap between scaffold and equipment be at least 1 inch, and prohibits tying off the scaffolding to conduit or unistrut conduit supports.
Contrary to the above, on July 12, 1994, a scaffold in the #1 lov voltage switchgear room was not erected in accordance with DB-MS-01637 in that a horizontal cross member was in contact with a louvre of a safety related ventilation damper, and the scaffold was braced with vire to two 3-inch safety related conduits and a safety related unistrut conduit support (346/94006-01b(DRP)).
c.
Procedure DB-0P-00006, Night Order / Standing Order Log, note 6.1 states that " Night orders shall not provide instructions which conflict with or substitute for approved procedures."
Contrary to the above, the night order log sheet issued to the operating crews on January 13, 1994, contained instructions that conflicted with approved procedure DB-0P-06331, Freeze Protection and Electrical Heat Trace, in that Section 3.2 of the procedure required work requests to be initiated for heat trace or freeze protection problems causing alarm conditions on the control room DORIC recorder.
However, the night order stated that when a heat trace or freeze protection problem was noted, the electrical shop personnel were to be notified.
If they were unable to review or solve the problem, submittal of the work request would then be allowed.
As a result of the conflicting guidance, work requests were not initiated for all heat trace and freeze protection problems (346/94006-01c(DRP)).
This is a Severity Level IV Violation (Supplement I).
Response
Acceptance or Denial of the Alleged Violation Toledo Edison accepts the alleged violation.
- Docket Number 50-346 License Number NPF-3 Serial Number 1-1050 Page 3 Reason for the Violation The three procedural adherence examples identified in the violation indicate that management expectations regarding compliance with procedures are not being. completely met.
In each case, a basic tenet of an administrative procedure was violated. While these violations were not blatant or malicious in nature, they are inconsistent with management procedural adherence expectations.
Personnel are expected to exercise the discretion and discipline necessary to ensure that procedural requirements are met.
The number and comprehensive nature of Davis-Besse procedures demand a conscious, continuous, high level of attention to detail regarding procedural adherence by personnel at all levels of craft and management. The apparent cause of this violation is insufficient attention to detail on the part of the individuals performing the identified activities and insufficient reinforcement by management to ensure that procedural adherence expectations were met.
l Corrective Actions Taken and Results Achieved Part a:
On June 30, 1994, Potential Condition Adverse to Quality Report (PCA0R) 94-0571 was initiated to document the procedure violation regarding inadequate foreign material.
exclusion in spent fuel pool area.
The FME access barrier was replaced and the FME material log was reconciled as part of PCA0R 94-0571 immediate actions.
Part b:
On July 12, 1994, PCA0R 94-0591 was initiated to document the procedure violation regarding a deficient scaffold installation in the #1 Lov Voltage Switchgear Room. The specific deficiencies were'immediately corrected.
All other plant scaffolding was subsequently inspected and no other discrepancies were identified.
Part c:
On January 31, 1994, PCA0R 94-0114 was initiated to document the procedure violation regarding work requests not being initiated for heat trace and' freeze protection problems. Vork requests were initiated as required on February 1, 1994. A memorandum was issued on February 15, 1994, by Electrical Maintenance which clarified the. actions being taken to address heat trace and freeze protection problems and reinforced the expectation that work requests are required. Required reading for Operations personnel was later initiated which reiterated the expectation that work requests are required for heat trace and freeze protection problems.
In addition, as an enhancement, LB-0P-06331 is being revised to clarify expected actions to address this problem.
~-
Docket Number 50-346 License Numbar NPF-3 Serial Number 1-1050 Page 4 Corrective Actions to Prevent Recurrence Toledo Edison recognizes the importance of procedural adherence to safe, reliable nuclear power plant operation.
It is Davis-Besse management's position that the procedural adherence issues identified by this violation, and their broader implications, are not the result of deficient employee training. Rather, these issues have developed over time due to a lack of sufficient reinforcement of management expectations and insufficient attention to detail on the part of plant staff.
~
I A memorandum from the Vice President - Nuclear addressing procedural adherence issues vill be distributed to all site personnel.
This memorandum vill reinforce the management expectation that each employee is responsible for exercising the attention to detail, discretion, and discipline necessary to ensure that procedural requirements are met.
The memorandum vill be issued by September 2, 1994.
To further reinforce these expectations, employee meetings will be conducted by Davis-Besse senior management to discuss procedural adherence issues. The meetings vill be conducted prior to the Ninth Refueling Outage which is scheduled to begin October 1, 1994.
Davis-Besse publishes a quarterly performance monitoring report using the " annunciator vindow" approach. The report monitors and trends a vide range of performance measures and provides Davis-Besse management with timely feedback on plant performance. The report consists of a visual _ display of colored vindows arranged in an annunciator panel format and is dicplayed on bulletin boards throughout the site.
Beginning in September 1994, and continuing initially for two full quarterly reporting periods, a focus vindow vill be developed and implemented to trend procedural. adherence issues.
Following this initial period, the procedural adherence focus vindov vill be evaluated to assess the benefits of continually maintaining this vindow in the performance monitoring report.
Independent of this violation, potential programmatic compliance issues had already been identified through the t
trending of PCA0Rs. The Nuclear Assurance organization has initiated a Suspected Trend Investigation Report (STIR) which will, in part, address the procedural adherence issues l
identified by this violation and which may result in additional corrective actions.
l
1 Docket Number 50-346 License Number NPF - *,.
Serial Number 1-1050'
~
Paga 5 Date When Full Compliance Vill Be Achieved Part as Full compliance was achieved on June 30, 1994, following the replacement of the FME access barrier and reconciliation of the FME material access log for the spent fuel pool area.
'Part b:
Full compliance was achieved on July 13, 1994, following the inspection of plant scaffolding to ensure compliance with the requirements of DB-MS-01637.
l Part c:
Full compliance was achieved on February 1, 1994, following the initiation of outstanding work requests for heat trace and freeze protection problems.
Should you have any questions or require additional information, please contact Mr. Villiam T. O'Connor, Manager - Regulatory Affairs, at (419) 249-2366.
V ry tr
.y yours, VA/ eld IS cc:
L. L. Gundrum, NRC Project Manager J. B. Martin, Regional Administrator, NRC Region III S. Stasek, DB-1 NRC Senior Resident Inspector Utility Radiological Safety Board t
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